Hanging Injuries and Strangulation Clinical Presentation

  • Author: William Ernoehazy Jr, MD, FACEP; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Nov 28, 2011
 

History

Several specific patterns of presentations are common.

  • Assault victims may present after being either manually strangled or garroted.
  • Hanging victims may be brought to the emergency department by Emergency Medical Services (EMS) after being found by strangers, friends, or family members. These patients may have been suicidal. However, they also may have been experimenting with autoerotic asphyxia, or other forms of "breath play," and were hanged by accident. (See Causes.) Attempts to determine the height of the drop in near-hanging victims are important, as different patterns of injury occur as the drop height increases. This, in turn, affects management.
  • Infants generally present after being caught by the neck between crib slats, fence slats, or on objects such as hanging window cords.
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Physical

  • Abrasions, lacerations, contusions, or edema to the neck, depending on how the patient was strangled
  • Subconjunctival and skin petechiae cephalad to the site of choking (Tardieu spots)
  • Severe pain on gentle palpation of the larynx, which may indicate laryngeal fracture[4]
  • Mild cough
  • Stridor
  • Muffled voice
  • Respiratory distress
  • Hypoxia (usually a late finding)
  • Mental status changes
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Causes

Common causes of strangulation injuries include the following:

  • Assault: Risk factors follow other types of assault, with the exception that women are more likely than men to be victims of strangulation.
  • Depression can lead to hangings, especially in subgroups (eg, prisons, where hangings are easier to do than other methods) or veterans.[5]
  • Erotic experimentation: Some people experiment with hypoxia as a means of intensifying orgasm. Marquis de Sade first described this practice in his writings. Autoerotic play using a ligature or noose to produce hypoxia during masturbation can result in accidental strangulation. Sado-masochistic activities can also result in inadvertent death.[6]
  • Another form of "breath play" is increasingly common among adolescent and young adults. Most commonly known as the "choking game," it involves voluntary choking, throttling, or near-hanging in order to enjoy the altered sensations that occur as the "player" becomes unconscious. Other slang names at this writing include "flatline," "space monkey," and "suffocation roulette."
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Contributor Information and Disclosures
Author

William Ernoehazy Jr, MD, FACEP  Medical Director, Emergency Department, Ed Fraser Memorial Hospital, Florida

William Ernoehazy Jr, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Dan Danzl, MD  Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David B Levy, DO, FACEP, FAAEM  Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

I wish to recognize the inspiration and help given by my father, Dr. William Ernoehazy, FACP (d. 2005), co-author of the original version of this article.

References

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  14. Kleinsasser NH, Priemer FG, Schulze W, et al. External trauma to the larynx: classification, diagnosis, therapy. Eur Arch Otorhinolaryngol. 2000;257(8):439-44. [Medline].

  15. Le D, Macnab AJ. Self strangulation by hanging from cloth towel dispensers in Canadian schools. Inj Prev. Sep 2001;7(3):231-3. [Medline].

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  17. Mohanty MK, Rastogi P, Kumar GP, et al. Periligature injuries in hanging. J Clin Forensic Med. Dec 2003;10(4):255-8. [Medline].

  18. National Safety Council. What are the odds of dying? [e11th-hour.org Web site]. August 15, 2004. Accessed August 1, 2005. [Full Text].

  19. Pesola GR, Westfal RE. Hanging-induced status epilepticus. Am J Emerg Med. Jan 1999;17(1):38-40. [Medline].

  20. Schild JA, Denneny EC. Evaluation and treatment of acute laryngeal fractures. Head Neck. Nov-Dec 1989;11(6):491-6. [Medline].

  21. Seabourne A, Seabourne G. Suicide or accident - self-killing in medieval England: series of 198 cases from the Eyre records. Br J Psychiatry. Jan 2001;178(1):42-7. [Medline].

  22. Shlamovitz GZ, Assia A, Ben-Sira L, et al. "Suffocation roulette": a case of recurrent syncope in an adolescent boy. Ann Emerg Med. Feb 2003;41(2):223-6. [Medline].

  23. US Statistical Abstract of the United States. Government Printing Office; 2003.

 
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